Understanding and defining sanitation insecurity: Women’s gendered experiences of urination, defecation and menstruation in rural Odisha, India.
Open accessAbstract
Background Research suggests that the lived experience of inadequate sanitation may contribute to poor health outcomes above and beyond pathogen exposure, particularly among women. The goal of this research was to understand women’s lived experiences of sanitation by documenting their urination-related, defecation-related and menstruation-related concerns, to use findings to develop a definition of sanitation insecurity among women in low-income settings and to develop a conceptual model to explain the factors that contribute to their experiences, including potential behavioural and health consequences. Methods We conducted 69 Free-List Interviews and eight focus group discussions in a rural population in Odisha, India to identify women’s sanitation concerns and to build an understanding of sanitation insecurity. Findings We found that women at different life stages in rural Odisha, India have a multitude of unaddressed urination, defecation and menstruation concerns. Concerns fell into four domains: the sociocultural context, the physical environment, the social environment and personal constraints. These varied by season, time of day, life stage and toilet ownership, and were linked with an array of adaptations (ie, suppression, withholding food and water) and consequences (ie, scolding, shame, fear). Our derived definition and conceptual model of sanitation insecurity reflect these four domains. Discussion To sincerely address women’s sanitation needs, our findings indicate that more is needed than facilities that change the physical environment alone. Efforts to enable urinating, defecating and managing menstruation independently, comfortably, safely, hygienically, privately, healthily, with dignity and as needed require transformative approaches that also address the gendered, sociocultural and social environments that impact women despite facility access. This research lays the groundwork for future sanitation studies to validate or refine the proposed definition and to assess women’s sanitation insecurity, even among those who have latrines, to determine what may be needed to improve women’s sanitation circumstances.
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Movement restrictions influenced women and girls' access to water and defecation, urination, and menstrual management locations, and are most widely reported in India.
“Movement restrictions influenced women and girls' access to water [101, 110, 178] and defecation, urination, and menstrual management locations, and are most widely reported in India [62, 135, 174, 181, 182, 184, 187], [101,110,187,[189][190][191].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Women reported different health concerns, mostly negative, based on life stage and circumstance, including pregnant women's fears related to sanitation-related superstitions, stress about accessing sanitation sites for women with trouble controlling urination or defecation, lower odds of good health for women reliant on bags, buckets, or open defecation, and difficulty/pain defecating and urin
“Women reported different health concerns, mostly negative, based on life stage and circumstance.Notably, pregnant women expressed health fears related to sanitationrelated superstitions (India [184, 189]), women with trouble controlling urination or defecation stressed about accessing sanitation sites (India [2]), women reliant on bags, buckets, or open defecation had substantially lower odds of”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Women reported challenges related to privacy and water, specifically concerning hygiene, including challenges obtaining privacy at water sources used for bathing, post-defecation cleansing, and washing, particularly during menstruation.
“Women reported challenges related to privacy and water, specifically concerning hygiene.Women and girls in Bangladesh, [199] India, [184, 189, 226] Indonesia, [115] and Mozambique [175, 261] described challenges obtaining privacy at water sources used for bathing, post-defecation cleansing, and washing, particularly during menstruation.”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Women in Nairobi, Kenya who rely on bags, buckets, or open defecation had lower odds of experiencing privacy; household or shared toilets do not always prevent women from being seen or heard while defecating.
“Women in Nairobi, Kenya who rely on bags, buckets, or open defecation had lower odds of experiencing privacy [256].Household or shared toilets do not always prevent women from being seen or heard while defecating [123, 184, 186].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Women coped with sanitation stressors by seeking social support, withholding food or drink, or changing the timing of sanitation behaviors, though adaptations could also cause stress.
“Women coped with sanitation stressors by seeking social support, withholding food or drink, or changing the timing of sanitation behaviors, though adaptations could also cause stress [168, 177, 184, 189].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Women who withheld food and water or suppressed urination and defecation when lacking access to safe, clean latrines reported experiencing urinary tract infections, headaches, stomach aches, constipation, diarrhea, and other illnesses.
“Women who withheld food and water or suppressed urination and defecation when lacking access to safe, clean latrines reported experiencing urinary tract infections, headaches, stomach aches, constipation, diarrhea, and other illnesses [135, 168, 172-174, 184, 190, 214, 248].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Women reported myriad sanitation-related stressors, including fear of being attacked by men or ghosts, being shamed for using open defecation sites, suppressing urination or defecation, withholding food and water, needing help to meet sanitation needs, being hurried while using shared facilities, sanitation-related costs, and lacking privacy or being seen by others, especially men, while openly
“Women reported myriad sanitation-related stressors, including fear of being attacked by men or ghosts, [177, 181, 184, 189, 229, 238] being shamed for using open defecation sites, [172] suppressing urination or defecation, [184] withholding food and water, [184] needing help to meet sanitation needs, [184] being hurried while using shared facilities, [168, 185, 188] sanitation-related costs, [170,”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Privacy of household and shared latrines is compromised by broken or missing doors, missing locks, and poor construction; women worried about being seen walking to latrines, waiting in queues, having others hear or smell their activity, or the proximity of latrines to houses, main roads, or public spaces.
“Privacy of household and shared latrines is compromised by broken [189] or missing doors, [184, 248] missing locks, [175,191,248,251] and poor construction [175,191,240,251].Furthermore, women worried about being seen walking to latrines; [189, 227] waiting in queues; [130] having others hear or smell their activity; [175] or the proximity of latrines to houses, main roads, or public spaces [69,1”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Social capital has facilitated sanitation access; women and girls have formed and maintained social connections when accessing sanitation locations, and sought social support to ensure privacy and safety and to protect reputations when urinating or defecating.
“Social capital has facilitated sanitation access.Women and girls have formed and maintained social connections when accessing sanitation locations, [130, 182, 189] and sought social support to ensure privacy and safety and to protect reputations when urinating or defecating [173, 182, 184, 187-190, 223, 226].”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
Rural Indian women reportedly suppressed urination and defecation urges when caregiving and household obligations were pressing.
“Rural Indian women reportedly suppressed urination and defecation urges when caregiving and household obligations were pressing [184]”
From Water, sanitation, and women’s empowerment: A systematic review and qualitative metasynthesis (2022) · cites this paper as [184]
These findings seem inconsistent with high reports of stress associated with menstrual management in studies amongst school girls in sub-Saharan Africa and among adult women in India.
“These findings seem inconsistent with high reports of stress associated with menstrual management in studies amongst school girls in sub-Saharan Africa [2,5,13,34], and among adult women in India [16,18,35].”
From The relationship between household sanitation and women’s experience of menstrual hygiene: Findings from a cross-sectional survey in Kaduna State, Nigeria. (2018) · cites this paper as [35]
Studies in India, and Odisha specifically, have explored women's MHM challenges beyond adolescence, but have focused primarily on issues related to WASH conditions.
“Studies in India, and Odisha specifically, have explored women’s MHM challenges beyond adolescence, but have focused primarily on issues related to water, sanitation, and hygiene (WASH) conditions, including sanitation insecurity, experiences with sanitation-related psychosocial stress, and reproductive tract infections [19, 28, 44–46].”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [19]
In many settings, menstrual blood-and by extension, menstruating women-were considered ritually impure or polluting.
“In many settings, menstrual blood—and by extension, menstruating women—were considered ritually impure or polluting”
From Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis (2019) · cites this paper as [16]
Wet seasons and weather presented challenges for thoroughly and discretely drying reusable menstrual materials.
“Wet seasons and weather presented challenges for thoroughly and discretely drying reusable menstrual materials [16, 79].”
From Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis (2019) · cites this paper as [16]
Studies with greater interpretive depth noted that a lack of confidence to manage menses influenced how women and girls perceived themselves and their bodies, internalising a sense that 'their bodies are beyond their control'.
“Studies with greater interpretive depth noted that a lack of confidence to manage menses influenced how women and girls perceived themselves and their bodies, internalising a sense that ‘their bodies are beyond their control’ [5, 16, 47].”
From Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis (2019) · cites this paper as [16]
Authors identified health impacts resulting from adherence to taboos such as dietary restrictions on the consumption of common foods, linked to fatigue, or withholding urination for fear of others observing menstrual blood in latrines.
“Authors identified health impacts resulting from adherence to taboos such as dietary restrictions on the consumption of common foods, linked to fatigue, or withholding urination for fear of others observing menstrual blood in latrines [16, 41, 56, 57].”
From Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis (2019) · cites this paper as [16]
Availability of a toilet still leaves an unmet need for addressing women's need for menstruation related privacy.
“Availability of a toilet still leaves an unmet need for addressing the women’s need for menstruation related privacy [38].”
From Menstrual hygiene management among women and adolescent girls in the aftermath of the earthquake in Nepal (2018) · cites this paper as [38]
In the south Asian context, especially in India and Nepal, menstruation comes with many social restrictions including for religious rituals.
“In the south Asian context especially in India and Nepal, menstruation comes with many social restrictions including for religious rituals [9, 12, 38].”
From Menstrual hygiene management among women and adolescent girls in the aftermath of the earthquake in Nepal (2018) · cites this paper as [38]
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Self-citation
- Authors
- Caruso, B. A., Clasen, T. F., Hadley, C., Yount, K. M., Haardörfer, R., Rout, M., Dasmohapatra, M., & Cooper, H. L.
- Affiliations
- Emory University (US)
- London School of Hygiene & Tropical Medicine (GB)
- Corresponding author
- Caruso, Bethany A
- ORCID
- Venue
- BMJ Global Health
- Publisher
- BMJ
- Published
- 2017-10
- Volume
- 2
- Issue
- 4
- Pages
- e000414
- ISSN
- 2059-7908 (ISSN-L)
- PMC
- PMC5640070
- OpenAlex
- W2762747131
- Cited by
- 165
- References
- 45
- Citations by year
- 2026: 20 · 2025: 20 · 2024: 13 · 2023: 16 · 2022: 23 · 2021: 31 · 2020: 21 · 2019: 10 · 2018: 9 · 2017: 1
- FWCI
- 23.37
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- BMJ Global Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Funders
- Bill and Melinda Gates Foundation
- National Institutes of Health
- Topics
- Social Sciences › Gender Studies › Gender Studies and Social Issues
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Physical Sciences › Environmental Science › Pollution › Energy and Environment Impacts
- Keywords
- micturition, defecation, menstruation, gendered experiences, rural Odisha, latrine ownership, socio-cultural barriers, stigma and shame, life stages, conceptual model
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